The Montefiore Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The hospital had a manifesto, called the ‘Monte Manifesto’ which set out its purpose and strategy, including investing in people, expanding the service offer, improving hospital performance, delivering strong financial results, building on safety and quality, and championing sustainability.

The service had a vision for what it wanted to achieve and a strategy to turn it into action. This vision reflected the overarching provider aims and objectives. Staff spoken with had awareness of how their work contributed to achieving targets.

Staff were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and carers as well as staff could raise concerns without fear.

Staff felt respected, supported and valued. Staff reported that the leadership culture was inclusive and how they felt valued and respected. Relationships between staff of all grades were positive, with strong teamwork and collaboration.

Staff felt motivated about the future and planned changes for the service.

Team and individual staff achievement, and success was recognised and celebrated. Staff were thanked for their work.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had access to effective support and development opportunities to maintain and enhance their skills and credibility. Leadership training was in place to strengthen governance and staff development. The hospital used talent and succession planning role profiles. Leadership and management training was used to help staff develop their leadership capability.

There was a clear management structure with defined lines of responsibility and accountability. The senior leadership team included the hospital director, interim director of clinical services, operations director and finance director. Staff told us leaders were visible, and supportive, and described an open-door culture. However, feedback about approachability was mixed, with some staff reporting variable access to senior leaders. Departmental managers worked clinically when required, and staff told us their direct managers were approachable, listened to concerns, and supported staff effectively. Overall, staff said they felt engaged, supported and valued.

The endoscopy service had a designated clinical lead and an endoscopy service lead who led the day-to-day service delivery. The oncology service was led by a senior nurse. Leaders were focused on providing clinical quality and positive experiences in the service. They attended daily service-wide planning meetings and safety huddles and monthly heads of department meetings. Endoscopy and cancer services also held departmental strategy meetings to focus on specific issues such as JAG accreditation and oncology pathways. All consultants working in the service had relevant current experience in the specialism.

The medical care service fostered a positive culture where people felt they could speak up and their voice would be heard.

The hospital followed the patient engagement and experience framework and held a monthly patient experience group. Patients, their families and carers were provided with information to explain how they could raise a concern and how this would be investigated. The Patient Engagement Lead carried out daily walk-rounds to speak to patients and identify any issues quickly.

Senior staff in the medical care service were encouraged to respond to immediate concerns or complaints with a view to resolution. The hospital also had Speak up Month. The hospital aimed to promote openness and had a Freedom to Speak Up Guardian (FTSUG), supported by trained ambassadors who held monthly sessions and reported themes directly to the senior leadership team.

Staff understood how to raise concerns, and leaders investigated issues sensitively and confidentially. However, despite these mechanisms, the 2025 staff survey showed that not all staff felt confident to speak up. Results indicated 60% of oncology staff reported they felt able to raise concerns, disagree or admit mistakes without fear of negative consequences. Staff had mixed feelings and some staff told us they did not always feel able to speak up or confident that their concerns would be taken seriously, whilst others shared more positive

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for everyone.

The service followed an equality of opportunity policy, which set out the organisation’s commitment to promoting equality and diversity in the workplace. The policy explained what equal opportunity meant, described different types of discrimination, and outlines how unacceptable behaviour was managed.

The service had an equality and inclusion strategy which set out how they would celebrate diverse cultures and abilities, educate people and adapt the building to meet needs of those using the facility. This is included a range of measure such as providing a dementia friendly room, celebrating key festivals and identifying champions to represent key groups. The site had a faith room for staff and visitors to access for quiet space and reflection.

Staff completed mandatory training in equality, diversity, inclusion and belonging. However, compliance rates varied across staff groups, ranging from 50% in pharmacy, 75% in physiotherapy and 100% across medical and surgery; consultants with practising privileges achieved 70% compliance.

Staff were able to apply to work flexibly if needed to account for personal circumstances such as caring responsibilities or health issues.

Data was submitted to the Workforce Race Equality Standard (WRES), however; this was at provider level and not specific to this service.

The service promoted a calendar of events and initiatives that celebrated different cultures and traditions throughout the year, this included race equality week, international Women's Day, pride month, South Asian heritage month and Black History Month. For example, the service celebrated pride month with rainbow cupcakes.

The service had mental health first aiders in each department with details displayed on notice boards throughout the hospital and named in daily safety huddles.

The medical care service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The medical care service operated some governance processes through various committees and on-site activities. Also, there was a range of information collected, monitored and communicated internally at the relevant committee meetings and was fed upwards to Spire Healthcare Limited. Performance data was analysed and compared within Spire Healthcare Limited and where improvements were needed at the location level, action plans were developed to make this happen.

The service held quarterly governance meetings involving key members of the senior leadership team, including the hospital safety, quality and risk (HospSQR) committee. The committee promoted a patient safety and learning‑focused culture, oversaw the quality and effectiveness of care, and monitored clinical and non‑clinical risks, including those recorded on the risk register and escalated through the risk assessment library. We reviewed meeting minutes and saw that a range of risks were discussed, and learning was shared across teams.

Patient safety incidents were investigated in line with the Patient Safety Incident Response Framework (PSIRF) and investigated by senior leaders.

Spire Healthcare Limited had established a target of 95% compliance [JW1] with mandatory training. Training data provided, dated February 2025, showed overall compliance across the hospital of 91%, and oncology 96%.

There was a medical advisory committee led by a chair and supported by the service leadership, there were regular medical advisory committee (MAC) meetings with documented decision making. Which included approval of practicing privileges and review of clinical outcomes of individual doctors. If there were any concerns with performance, there were processes to follow and if necessary, information would be shared with professional bodies as required.

Staff at all levels were clear about their roles and accountabilities. Staff had job descriptions, and these set out expectations and responsibilities. Where senior staff had designated tasks related to audit and monitoring quality of services, they understood what was required of them.

The service followed safer recruitment and selection policy, which supported safe recruitment practices across the organisation. The policy set out pre‑employment screening requirements for all staff, including senior leadership and director roles, and ensured that individuals appointed to these positions met the Fit and Proper Persons Requirement (FPPR).

Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required.

Risks were clearly identified and a formal log of these was used to keep oversight and manage mitigations and/or bring to resolution. Staff contributed to decision-making to help improve sustainability and improve quality of care. The service maintained a risk register locally. Risks were mainly health and safety and environmental risks. The register included review dates and controls in place to mitigate risks.

Audit processes and the outcomes were used to ensure quality of services was maximised. Where improvements were required, leaders ensured action plans and the monitoring of these led to positive changes.

The service had plans to cope with unexpected events and had a business continuity plan, which included major incident plans.

The service had reported data breaches and systems. There was a designated information governance lead with responsibility for oversight of information handling and data protection compliance. The service reported 4 information governance incidents in the 12 months prior to the assessment. Patient identifiable information was handled correctly.

We reviewed several service level and provider policies and found these were up to date and readily available to staff. There was leadership oversight of the accuracy and validity of each policy. The provider had appropriate service level agreements, including arrangements for multidisciplinary team input for cancer services and a critical care transfer agreement. These agreements were signed and dated by all relevant parties, supporting continuity of care and escalation when required

The medical care service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

The medical care service worked collaboratively with external partners to improve patient outcomes and ensure joined-up care.

The medical care service demonstrated effective partnership working with its local NHS trust and wider health system. It provided commissioned services to support NHS waiting time pressures, evidencing a responsive and collaborative approach to local system needs. Leaders described regular engagement with the local Integrated Care Board (ICB), with the Director of Clinical Services providing routine updates to maintain transparency, oversight, and alignment with system priorities.

Formal governance arrangements were in place to support integrated care. The medical care service held Service Level Agreements for multidisciplinary team (MDT) support for cancer patients, ensuring timely access to specialist expertise and continuity of care across organisational boundaries. The endoscopy service hosted the Sussex Bowel Cancer Screening Programme, further demonstrating its role as an active system partner in population health and early cancer detection.

The medical care service also contributed to workforce development and shared learning across the local health economy. It delivered monthly update and training sessions for local GPs, physiotherapists, and other members of the wider medical community. These sessions focused on sharing up‑to‑date, evidence‑based best practice in the diagnosis and treatment of a range of medical and surgical conditions, supporting consistent, high‑quality care pathways.

Leaders provided examples of education events in cancer, which were designed to improve knowledge, confidence, and clinical understanding among partner organisations. This proactive approach supported integrated working, strengthened professional relationships, and contributed to improved coordination of patient care across services.

Overall, the medical care service demonstrated a clear commitment to collaboration, shared learning, and system leadership. Partnership arrangements were structured, purposeful, and embedded into governance processes, supporting effective integration and positive outcomes for patients.

The medical care service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff actively contributed to safe, effective practice and research.

The oncology service demonstrated a proactive approach to quality improvement, innovation, and learning, supported by organisational leadership and staff engagement. Leaders provided examples of organisation‑led quality improvement projects designed to improve patient outcomes and operational effectiveness. For example, staff were actively involved in evaluating new approaches to improve patient safety. They described participation in a trial aimed at reducing extravasation injuries using infusion site surveillance technology. This trial was informed by published research in the British Journal of Nursing and was being evaluated to determine its effectiveness in improving patient outcomes. Leaders told us that, if successful, this technology would be rolled out across the wider organisation, demonstrating a structured approach to evidence‑based innovation and learning.

The service showed a commitment to research and the responsible introduction of new procedures. Leaders provided evidence of research studies and clinical trials that had been considered for participation and submitted to Spire Healthcare’s Spire Healthcare Limited’s New Procedures and Research Committee for review. For example, a trial to reduce extravasation injury in patients receiving cancer treatment. This demonstrated effective governance and oversight of research activity, ensuring potential benefits and risks were appropriately assessed before implementation.

The cancer service demonstrated a holistic approach to patient care, including the provision of a dedicated garden area within the cancer suite to promote patient wellbeing and support recovery during treatment.

Workforce development and service resilience were also addressed through innovative role development. The oncology service had trained a pharmacy technician in cancer medication to provide cover during periods when the specialist oncology pharmacist was on leave. This ensured continuity of care, reduced service disruption, and supported staff development while maintaining patient safety.